Presbyterian Dual Plus (HMO D-SNP) Formulary



Below is the 2023 Formulary, or prescription drug list, from Presbyterian Dual Plus (HMO D-SNP) by Presbyterian Health Plan. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a New Mexico Medicare Part-C plan that covers your prescriptions. It also helps you compare costs among Medicare Part D and Medicare Advantage plans available to you. You’ll want to make sure the medicines you are currently taking are covered under any plans you are considering enrolling in.

This Presbyterian Dual Plus (HMO D-SNP)(H3204-013) plan has a $505 drug deductible. A deductible is the amount of expenses that must be paid out of pocket before the Initial Coverage period begins. However, some drugs do not require that the deductible is met before you receive coverage. You can see if the deductible is required below in the "Does the Deductible Apply" column. The Initial Coverage Limit (ICL) for this plan is $4660. The Initial Coverage Period is the period after the Deductible has been met but before the Coverage Gap phase. Once you and your plan provider have spent $4660 on covered drugs. (Combined amount plus your deductible) You will enter the coverage gap. (AKA "donut hole") Once you reach the coverage gap you will be required to pay 25% of the plan's cost for covered brand-name prescription drugs unless your plan offers additional coverage. You can see if this plan offers coverage in the "donut hole" by clicking the "Coverage Gap" link above the chart.

In 2023 if you have spent $7400 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. Presbyterian Health Plan will begin paying approximately 95% of your covered medication expenses. You can see if this plan covers your drugs in the Catastrophic Phase by clicking the "Catastrophic" link above the chart.



Plan Overview

Plan Name:Presbyterian Dual Plus (HMO D-SNP)
Plan ID: H3204-013
Provider: Presbyterian Health Plan
Plan Year:2023
Premium:$36.40
Deductible:$505
Initial Coverage Limit:$4660
Coverage Area:New Mexico
Similar Plan:H3204-015


Change Table Options:

Drugs Starting Letter:
Coverage Phase:

*Tip Click the Drug name to Compare Coverage and Retail Cost for Every Plan In Your Area
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Drug
Name⇅
Tier
Level
Deductible
Apply
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Paliperidone
4YNA43%NA1/1NY
Pancreaze
5NA25%NANN
Panretin
5NA25%NANN
Paricalcitol
4YNA43%NANN
Paromomycin Sulfate
2YNA$11NANN
Paroxetine
3YNA$47NAYN
Paroxetine Hydrochloride
2YNA$11NAYN
Paser
4YNA43%NANN
Paxil
3YNA$47NAYN
Pediarix
3YNA$47NANN
Pedvaxhib
3YNA$47NANN
Peg-3350 And Electrolytes
2YNA$11NANN
Pegasys
5NA25%NANN
Pemazyre
5NA25%NA14/21YN
Penicillamine
5NA25%NAYN
Penicillin V Potassium
2YNA$11NANN
Pentacel
3YNA$47NANN
Pentamidine Isethionate
4YNA43%NAYN
Pentasa
5NA25%NA8/1NN
Pentoxifylline
2YNA$11NANN
Periogard Alcohol Free
3YNA$47NANN
Permethrin
2YNA$11NANN
Perphenazine
3YNA$47NANN
Perseris
5NA25%NAYN
Phenelzine Sulfate
2YNA$11NANN
Phenobarbital
2YNA$11NANN
Phenytoin
2YNA$11NANN
Phospholine Iodide
3YNA$47NANN
Pifeltro
5NA25%NA1/1NN
Pilocarpine Hydrochloride
2YNA$11NANN
Pimozide
2YNA$11NANN
Pindolol
2YNA$11NANN
Pioglitazone And Glimepiride
4YNA43%NA1/1NN
Piperacillin And Tazobactam
4YNA43%NANN
Piqray
5NA25%NA2/1YN
Pirmella 1/35
3YNA$47NANN
Piroxicam
2YNA$11NANN
Plenamine
3YNA$47NAYN
Podofilox
2YNA$11NANN
Polyethylene Glycol 3350, Sodium Chloride, Sodium
2YNA$11NANN
Polymyxin B Sulfate And Trimethoprim
2YNA$11NANN
Portia
3YNA$47NANN
Potassium Chloride
2YNA$11NANN
Potassium Citrate
2YNA$11NANN
Pradaxa
4YNA43%NA2/1NN
Prasugrel
4YNA43%NA1/1NN
Pravastatin Sodium
1NNA$0NANN
Praziquantel
3YNA$47NANN
Prazosin Hydrochloride
1NNA$0NANN
Prednisolone Acetate
3YNA$47NANN
Prednisolone Sodium Phosphate
3YNA$47NANN
Prednisone
2YNA$11NANN
Prednisone Intensol
3YNA$47NANN
Prefest
4YNA43%NAYN
Pregabalin
2YNA$11NANN
Premarin
3YNA$47NAYN
Premphase
3YNA$47NAYN
Prempro
3YNA$47NAYN
Prevymis
5NA25%NA1/1NY
Prezcobix
5NA25%NA2/1NN
Prezista
5NA25%NA1/1NN
Priftin
3YNA$47NANN
Primaquine Phosphate
3YNA$47NANN
Primidone
2YNA$11NANN
Proair Respiclick
4YNA43%NANN
Probenecid
2YNA$11NANN
Probenecid And Colchicine
2YNA$11NANN
Prochlorperazine Maleate
2YNA$11NANN
Procto-med Hc
2YNA$11NANN
Proctosol-hc
3YNA$47NANN
Proctozone-hc
3YNA$47NANN
Progesterone
2YNA$11NANN
Prograf
4YNA43%NAYN
Prolastin-c
5NA25%NAYN
Prolia
4YNA43%NA1/180YN
Promacta
5NA25%NA6/1YN
Promethazine Hydrochloride
2YNA$11NANN
Propafenone Hydrochloride
2YNA$11NANN
Propranolol Hydrochloride
2YNA$11NANN
Propylthiouracil
2YNA$11NANN
Proquad
3YNA$47NANN
Protriptyline Hydrochloride
2YNA$11NAYN
Prudoxin
4YNA43%NANN
Pulmicort
4YNA43%NANN
Pulmozyme
5NA25%NAYN
Purixan
5NA25%NAYN
Pyrazinamide
2YNA$11NANN
Pyridostigmine Bromide
5NA25%NANN
Pyrimethamine
5NA25%NAYN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H3204-013

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $505. Some plans offer select Pre-deductible drug Coverage
2. Initial Coverage: (ICL) After you reach the plans deductible but before the Initial Coverage limit of $4660
3. Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $7400 in 2023.
4. Catastrophic: Anything over $7400 you will receive a significant increase in coverage.

Definitions:

Premium: A monthly flat fee that varies by plan.
Deductible: The amount you must pay each year for your prescriptions before your plan begins to pay its share of your covered drugs. The max in 2023 is $505. Some plans have a $0 Deductible.
Tier Level: Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost. A drug in a lower tier will generally cost you less.
Quantity Limit Amount/Days: Certain drugs have a Quantity Limit. That means the plan will only cover the drug up to a designated quantity or amount. If your prescribing doctor feels it is necessary to exceed the set limit, he or she must get prior approval before the higher quantity will be covered.
Prior Authorization: Certain Drugs require you or your doctor to get prior authorization to be covered. Usually just an additional form. If you dont get approval, the plan may not cover the drug.
Does the Deduct Apply: Some drugs do not require that the deductible is met before you receive coverage.
Step Therapy: Means you must first try one drug to treat your medical condition before the plan will cover another drug for the same condition. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Cost Preferred: Your Cost for the Drug at the Providers In-Network Preferred Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Non-Preferred: Your Cost for the Prescription Drug at a Non-Preferred Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Mail: Your Cost for Prescription Drugs through a Mail Order Pharmacy. As a Percent of the total drug cost or a flat rate.


What if a drug I need is not listed?

Please check the formulary for different brand and generic names. If you still cannot locate your drugs, your plan may not offer coverage. Talk to your doctor first about changing your prescription to a drug on your plan's formulary. If this is not an option, you can request an exception to have the plan review its coverage decision based on your individual circumstances.

Last updated on

Source:CMS Formulary Data Q4 2022
Source:NDC Directory by FDA.gov

**We make every attempt to keep our information accurate. But please check with the plan providers to verify all information.

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